This is the lay version of the EULAR \u2018points to consider\u2019 for the diagnosis and management of rheumatic
\nimmune-related side effects in people taking checkpoint inhibitors for cancer. The original publication can be
\ndownloaded from the EULAR website: www.eular.org.
\nKostine M, et al. EULAR points to consider for the diagnosis and management of rheumatic immune-related
\nadverse events due to cancer immunotherapy with checkpoint inhibitors. Ann Rheum Dis 2021;80:36\u201348.
\ndoi:10.1136\/annrheumdis-2020-217139<\/p>\n
Introduction<\/strong> What do we already know?<\/strong> What do the points say?<\/strong> \u2022 Rheumatologists should be aware of the wide spectrum of rheumatic immune-related adverse<\/strong> \u2022 Oncologists should consult rheumatologists quickly when rheumatic symptoms are suspected<\/strong> \u2022 Some side effects of the cancer itself or unrelated rheumatic diseases might look like immune-<\/strong> \u2022 If other treatments do not work, steroids can be considered for symptoms that look like immune-<\/strong> \u2022 csDMARD should be considered in people with insufficient response to glucocorticoids or those<\/strong> \u2022 bDMARDs can be considered for people with severe rheumatic and connective tissue disease-<\/strong> \u2022 The decision to stop or to continue cancer immunotherapy should be made with the patient,<\/strong> \u2022 Myositis may be a severe condition, and stopping cancer immunotherapy needs to be discussed.<\/strong> \u2022 Cancer immunotherapy can be used in people who have a pre-existing autoimmune rheumatic<\/strong> \u2022 There is no need to test for autoantibodies before starting cancer immunotherapy, but these<\/strong> Summary<\/strong> Disclaimer<\/strong>\u00a0: This is a summary of a scientific article written by a medical professional (\u201cthe Original Article\u201d). The Summary is written to assist non medically trained readers to understand general points of the Original Article. It is supplied \u201cas is\u201d without any warranty. You should note that the Original Article (and Summary) may not be fully relevant nor accurate as medical science is constantly changing and errors can occur. It is therefore very important that readers not rely on the content in the Summary and consult their medical professionals for all aspects of their health care and only rely on the Summary if directed to do so by their medical professional. Please view our full\u00a0Website Terms and Conditions<\/a>.<\/p>\n Copyright<\/strong>\u00a0\u00a9 2021 BMJ Publishing Group Ltd & European League Against Rheumatism. Medical professionals may print copies for their and their patients and students non commercial use. Other individuals may print a single copy for their personal, non commercial use. For other uses please contact our\u00a0Rights and Licensing Team<\/a>.<\/p>\n","protected":false},"excerpt":{"rendered":" This is the lay version of the EULAR \u2018points to consider\u2019 for the diagnosis and management of rheumatic immune-related side effects in people taking checkpoint inhibitors for cancer. The original publication can be downloaded from the EULAR website: www.eular.org. Kostine M, et al. EULAR points to consider for the diagnosis and management of rheumatic immune-related […]<\/p>\n
\nEULAR recommendations give advice to doctors, nurses and patients about the best way to treat and
\nmanage diseases. EULAR has written new \u2018points to consider\u2019 on how to diagnose and manage rheumatic
\nimmune-related side effects in people taking a type of cancer drug called a checkpoint inhibitor.
\nDoctors, nurses, other health professionals and patients worked together to develop this advice. The patients
\nin the team ensured that the patient point of view was included.<\/p>\n
\nCheckpoint inhibitors act on the immune system to treat several types of cancer. This group of drugs
\nincludes ipilimumab, nivolumab, pembrolizumab, cemiplimab, atezolizumab, avelumab and durvalumab.
\nAbout 10% of people who take a checkpoint inhibitor drug to treat a cancer develop musculoskeletal side
\neffects called immune-related adverse events (shorted to irAEs).
\nEULAR has written a set of \u2018points to consider\u2019 on how rheumatic irAEs should be diagnosed and managed.
\nThese aim to help oncologists and rheumatologists work together to treat people who develop these side
\neffects. At the moment there is a very low level of evidence on this subject, so it is not possible to develop full
\nrecommendations.<\/p>\n
\nIn total, there are 4 overarching principles and 10 points to consider. The principles highlight that these
\nrheumatic and musculoskeletal irAEs are common in people taking checkpoint inhibitors, and should be
\nmanaged on a shared-decision basis between patients, their treating oncologist, and the rheumatology team.
\nRheumatologists should work to assist the oncologist in differential diagnosis, and help to relieve symptoms
\nto enable patients to maintain their cancer immunotherapy.
\nEach point is based on the best current knowledge and studies of scientific evidence or expert opinion. The
\nmore stars a point has the stronger the evidence is. However, even recommendations with limited scientific
\nevidence may be important, because the experts may still have a strong opinion and the evidence may be
\nlagging behind.
\nOne star (*) means it is a recommendation with limited scientific evidence.
\nTwo stars (**) means it is a recommendation with some scientific evidence.
\nThree stars (***) means it is a recommendation with quite a lot of scientific evidence.
\nFour stars (****) means it is a recommendation supported with a lot of scientific evidence.<\/p>\n
\nevents that often do not fulfil traditional criteria of rheumatic diseases.*<\/strong>
\nThere is a lot of variation in the types of irAEs that people get from checkpoint inhibitors. These can
\ninclude arthritis and joint pain, myositis, dry mouth, skin thickening, fever, fatigue, etc. Rheumatologists
\nshould be aware of the possible symptoms that can mimic rheumatic diseases.<\/p>\n
\ndue to immunotherapy, and rheumatologists should provide access for these patients.*<\/strong>
\nIf people taking checkpoint inhibitors develop rheumatic irAEs, their treating oncologist should quickly
\nrefer them to a rheumatologist, ideally before trying any steroid treatment. Rheumatologists should see
\nthese patients quickly as they are best-placed to try low-dose or steroid-sparing treatments.<\/p>\n
\nrelated events. Clinical evidence, laboratory tests, imaging and biopsies should be collected to<\/strong>
\nsearch for inflammation and exclude other diseases.*<\/strong>
\nCheckpoint inhibitors are often used in people with advanced cancer, and so new rheumatic or
\nmusculoskeletal symptoms may not always be irAEs. The oncology team should collect clinical evidence
\nto rule out cancer progression. It is important that this is done quickly to ensure the correct treatment can
\nbe given. Then, the rheumatologist should collect evidence of inflammation (on joints, on muscles, on
\nvessels, etc…) either by clinical evidence, or blood tests and imaging, and if required with biospies.<\/p>\n
\nrelated rheumatic or connective tissue diseases.*<\/strong>
\nIf treatment with painkillers or non-steroidal anti-inflammatory drugs does not work to control your
\nsymptoms, you may be offered glucocorticoids (steroids). This will depend on your particular set of
\nsymptoms, but steroids injections or tablets can be useful for arthritis or joint pain. Once your irAE
\nsymptoms have improved, the steroid should be reduced to the lowest dose needed to maintain control.
\nThis is because steroids used for a long time or at a high dose can cause side effects or may alter how
\nyour tumour responds to treatment.<\/p>\n
\nrequiring glucocorticoid-sparing.*<\/strong>
\nIf steroids do not work to control your symptoms \u2013 or if they only work for you at a high dose (more than
\n10 mg per day) \u2013 then you may be offered a conventional synthetic disease-modifying antirheumatic
\ndrug instead (often shortened to csDMARD). These types of drugs include methotrexate,
\nhydroxychloroquine or sulfasalazine.<\/p>\n
\nlike immune-related adverse events or those with insufficient response to csDMARDs.*<\/strong>
\nPeople experiencing severe rheumatic and systemic irAEs, or those with an insufficient response to
\ncsDMARDs can try a biologic (also called a bDMARD). For people with symptoms of inflammatory
\narthritis, the preferred options are TNF or IL-6 inhibitors.<\/p>\n
\nbased on side effect severity, the tumour response and duration, and the treatment plan.*<\/strong>
\nAt the moment there is no agreement about whether people with irAEs should stay on the checkpoint
\ninhibitor. This might vary depending on your country or treating team, but you should be involved in the
\ndiscussions and decision-making.<\/p>\n
\nIf there are life-threatening symptoms, other treatment options can be used instead.*<\/strong>
\nMyositis is inflammation in a person\u2019s muscles, causing weakness and pain. Myositis can also affect the
\nmuscles of the heart, which can potentially be fatal. If myositis is suspected, it may be necessary to stop
\nthe checkpoint inhibitor. People who have life-threatening symptoms such as dysphagia, dysarthria,
\ndysphonia, dyspnoea or myocarditis can be treated with high-dose glucocorticoids, intravenous
\nimmunoglobulin (IVIg) and\/or plasma exchange.<\/p>\n
\ndisease, while keeping their immunosuppressive treatment for the rheumatic disease at the<\/strong>
\nlowest dose possible.*<\/strong>
\nPeople with pre-existing inflammatory or autoimmune diseases can take checkpoint inhibitors for cancer,
\nbut they and their treating team should be aware that they may experience disease flares. In most cases,
\nthese flares can be managed with steroids.<\/p>\n
\nshould be checked if there are rheumatic, musculoskeletal or systemic symptoms.*<\/strong>
\nAutoantibodies are not always present in people with irAEs, so there is no need to test everyone before
\nthey start treatment with a checkpoint inhibitor. However, it can be useful as part of a complete
\nrheumatology assessment if you have unexplained rheumatic, musculoskeletal or systemic symptoms.<\/p>\n
\nOverall, these points to consider provide the basis of a EULAR consensus in a new and rapidly expanding
\nfield. Early consultation and strong collaboration between the referring oncologist, the treating
\nrheumatologist, other organ specialists and the patient are all required for optimal management.
\nRecommendations with just one or two stars are based mainly on expert opinion and may not be backed up
\nsufficiently yet by studies. These may be as important as those with three or four stars.
\nIf you have any questions or concerns about your disease or your medication, you should speak to a health professional involved in your care.<\/p>\n